Improving laboratory test utilisation at the multihospital Yale New Haven Health System

BackgroundWaste persists in healthcare and negatively impacts patients. Clinicians have direct control over test ordering and ongoing international efforts to improve test utilisation have identified multifaceted approaches as critical to the success of interventions. Prior to 2015, Yale New Haven Health lacked a coherent strategy for laboratory test utilisation management.MethodsIn 2015, a system-wide laboratory formulary committee was formed at Yale New Haven Health to manage multiple interventions designed to improve test utilisation. We report here on specific interventions conducted between 2015 and 2017 including reduction of (1) obsolete or misused testing, (2) duplicate orders, and (3) daily routine lab testing. These interventions were driven by a combination of modifications to computerised physician order entry, test utilisation dashboards and physician education. Measurements included test order volume, blood savings and cost savings.ResultsTesting for a number of obsolete/misused analytes was eliminated or significantly decreased depending on alert rule at order entry. Hard stops significantly decreased duplicate testing and educational sessions significantly decreased daily orders of routine labs and increased blood savings but the impact waned over time for select groups. In total, we realised approximately $100 000 of cost savings during the study period.ConclusionThrough a multifaceted approach to utilisation management, we show significant reductions in low-value clinical testing that have led to modest but significant savings in both costs and patients’ blood.

Reducing red blood cell folate testing: a case study in utilisation management

Mandatory enrichment of wheat flour in Canada with folic acid since 1998 has caused folate deficiency to be rare. There were 3019 red blood cell (RBC) folate tests performed during an 18-month period at London Health Sciences Centre (LHSC)/St. Joseph’s Healthcare London (SJHC) without any folate deficiency detected. We implemented a quality improvement initiative to reduce RBC folate testing at LHSC/SJHC. We began with a retrospective review of RBC folate tests performed during the previous 18 months. We identified physicians who had ordered more than five tests during this period and sent them an educational email to inform them of our intentions and solicit their input. We then discontinued RBC folate testing in-house and a pop-up window was introduced to the computerised physician order entry system stating that biochemist approval would be needed before samples would be sent out for testing. During the audited 18-month period, the average monthly test volume was 168 (SD 20). The three departments ordering the most RBC folate testing were nephrology (15%), haematology (7%) and oncology (7%). Physician feedback was supportive of the change, and during the 2 months after targeted email correspondence, the average monthly test volume decreased 24% (p<0.01) to 128 (SD 1). On discontinuation of the test in-house and implementation of the pop-up, the average monthly test volume decreased another 74% (p<0.01) to 3 (SD 2). In the 10 months following discontinuation of the test on-site, there were only 39 RBC folate tests performed with no deficiency detected. This initiative significantly reduced unnecessary RBC folate orders. The change in ordering on email contact suggests that physician education was an important factor reducing overutilisation. However, the most significant decrease came from restricting the test so that only orders approved by a biochemist would be performed.

Plant taxonomic capacity in South Africa

South Africa’s exceptionally rich and diverse flora faces challenges in terms of utilisation, management and conservation; these actions are underpinned by taxonomic research. The principal purpose of this review is to determine whether South Africa has the human capacity and resources to conduct taxonomic research that is required to support end-users of plant taxonomic information, and to identify shortages of capacity or resources that might prove to be an obstacle for plant taxonomic research. From an analysis of the existing gaps in taxonomic information, current research trends, and resources, it is apparent that there is a critical shortage of human capacity in South Africa to conduct plant taxonomic research for the benefit of biodiversity and society. Training institutions need to ensure the supply of suitably trained graduates including concentrating on those who meet Employment Equity targets. The need for more taxonomists is clearly justified, but may not be a priority in a country that already has such shortages of capacity in education and social services. Aside from lobbying for more jobs to be created, there is an urgent need to utilise available resources (human and other) effectively, and to implement a strategy for taxonomic research to ensure that priority activities are conducted.

Technical Challenges in 4G Cognitive Femtocell Systems

This chapter studies the application of femtocells as part of the future cognitive 4G networks. It starts with a demonstration for the evolution of cellular and wireless networks. The developing technology that leads towards a converged LTE-Femtocell wireless environment is described in detail. The chapter presents the key challenges of deploying cognitive femtocell in the macrocell networks. As spectrum utilisation management is the main concern in the future network, the main models for spectrum allocation used to provide enough bandwidth to the femtocell in coexistence with the LTE systems are incorporated for further investigation. In addition, the Quality of Service (QoS) provisioning and the main approaches for measuring end user performance are given as function small range transmission domains. The requirement of an effective mobility management solution in such systems is analysed for future development. The chapter is concluded with a summary.

Managed Care: US Research Evidence and its Lessons for the NHS

Objectives: To review the high quality US evidence on performance of managed health care organisations and the available US evidence on specific managed care techniques; namely, financial incentives, utilisation management and review, physician profiling and disease management. Methods: Literature searches were conducted using numerous databases including Medline, Embase, the Social Sciences Citation Index and the National Health Service (NHS) Centre for Reviews and Dissemination library. For inclusion of evaluations of overall performance, studies had to use a comparison group (typically fee-for-service patients), make appropriate statistical adjustments for differences between groups, and be published in a peer-reviewed journal from 1980 forward. For assessments of techniques, less-demanding inclusion criteria reflected the paucity of generalisable literature; however, more current results were required (1990 forward). Results: We identified 70 articles for systematic review, covering 18 dimensions of performance (e.g. utilisation, quality of care, consumer satisfaction, equity). The strength of the evidence varied by dimension. It was strongest for utilisation and quality. In general, managed care seems to reduce hospitalisation and use of high-cost discretionary services, to increase preventive screening, and to be neutral in terms of patient outcomes. As for specific techniques, we identified 19 articles for review, but limitations of these studies prevented our drawing any definite conclusions about techniques' effectiveness. This is an important, if somewhat negative, conclusion. Conclusions: Applying US evidence is complicated by an irrelevant comparator and a higher baseline of utilisation. Managed care brought Americans the familiar NHS practices of population-based health care and resource management through gatekeeping; hence, changes due to UK adoption of managed care techniques may be modest. US evidence should be used to generate hypotheses, not to predict UK behaviour.